PSIMED is offering a secure and convenient payment method for the portion of services that your insurance does not cover, but for which you are responsible. This includes annual deductibles, co-payments and co-insurance. Your credit card information will be kept confidential and secure. No payments will be processed until you provide the amount to be charge and the verbal consent to do so.
I First Name Last Name, authorize PSIMED to capture my credit card information. I understand and agree that this payment will only be processed after I have given the amount to be charged and verbal consent to do so. I understand and agree that PSIMED will only mail a receipt upon request.
I understand and agree that this form will remain valid until I provide a 30-day written notice to cancel the authorization to
PSIMED 1111 Van Voorhis Road, Suit J Morgantown, WV 26505
I certify that I am an authorized user of this credit card and that I will not dispute the payment with the credit card company, so long as the transaction corresponds with the agreed upon terms indicated on this form.
Patients Name: First Name Last Name Patients DOB: Date Card Holder's Name (as shown on card) First Name Last Name Card Type: Visa Mastercard Discover American Express Credit Card Number__________________________ Expiration Date: Date CVV Code_____________________ Billing Zip Code ____________Cardholder Signature: Signature Date: Date